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Aviation Human Factors Industry News

July 27, 2006

Vol. II, Issue 26.

Investigators examining what caused an Armenian airliner to crash with the loss of all 113 people on board have blamed pilot error.

IAC: A320 crash caused by inadequate actions of the captain

The Chief Department of Civil Aviation of Armenia has received the official findings of the Interstate Aviation Committee (IAC) concerning the crash of the Armenian Airbus A320 plane that fell into the Black Sea while flying from Yerevan to Sochi on May 3. The press service of the Department has informed REGNUM of the content of the findings:

"The investigation has shown:   With autopilot turned on, the plane was gliding strictly within the landing configuration and was already 300 meters high when the air controller instructed the crew to stop landing because of low clouds, and to make a climbing turn. When turning, the captain turned off the autopilot and, after climbing for a while, with improper bank and pitch attitude, began to land the aircraft – thereby, acting inadequately. Meanwhile, the second pilot failed to properly control the landing parameters (pitch, altitude, vertical speed). When the terrain warning system went off, the crew’s actions were poorly coordinated and insufficient for pulling the plane up. No single system failed, the aircraft adequately reacted to both the instructions of the autopilot and the actions of the crew. There was enough fuel for safe landing."

During the investigation the commissioners collected and examined all relevant data on the aircraft, the crew and the services controlling the flight, decoded and analyzed the data of the black boxes and the land air control services. With the help of special stands and trainers, a group of Russian, Armenian and French specialists simulated the whole flight, including the actions of the pilots.

To remind, the A320 fell into the Black Sea near Sochi, 6 km away from the shore, on May 3, 2006 02:13 AM. All the 8 crew members and 105 passengers onboard were killed.

Nods to reality

Anyone who has taken a "power nap" knows how refreshed you can feel after 10 or 20 minutes of shut-eye. So it would be a good idea — odd as it might sound — if the pilots on long flights were allowed to do the same thing. One at a time, of course, and with strict safeguards.

Sleepy pilots.

Yes, you can almost hear the late-night TV comedians advising passengers: "In addition to your usual exit row duties, we'll also be asking you to make sure the pilots are awake before landing." In fact, fear of the Jay Leno factor is a very real reason why regulators steer clear of this common sense idea. But that shouldn't block otherwise rational federal policy.

The Federal Aviation Administration doesn't explicitly prohibit in-flight napping, but it doesn't permit it, either. Pilots know that flying while sleeping would violate the FAA's blanket ban against "careless and reckless" behavior. But they do it anyway, for reasons one pilot frankly and convincingly describes on today's Forum page.

On overnight flights, there's a limit to what coffee can do. A NASA study of fatigue found that tired people can experience brief periods of "microsleep," seconds- or even minutes-long lapses when the eyes can be open but the brain is on hold. This is not what you want when your pilot is flying a demanding instrument approach through turbulence, rain and low clouds at the end of a 7-hour flight that began at midnight.

What to do? Acknowledge reality, and permit controlled napping on lengthy flights with two pilots. Allow one to take brief naps during the long stretches of cruise flight when the plane is on autopilot, and set up a system to make sure the other is awake. Require, for example, a flight attendant to check in over the intercom with the non-sleeping pilot every 15 minutes or so. Or install a panel device that periodically requires the awake pilot to reset it to avoid a loud alarm.

Fatigue is a killer. Aviation history is full of deadly crashes in which tired pilots made crucial mistakes they might have avoided if they had been rested. Power napping can help ensure they're alert at the right times.

The larger issue is finding the optimal balance between rest and on-duty time for pilots. The FAA has wrestled since 1995 with changes to the existing regulations and can't get consensus among pilots and carriers.

In the meantime, what worked in kindergarten still makes sense. Hold the milk and cookies, perhaps, but don't skip the nap.

NTSB concerned rules don’t apply to aging planes

WASHINGTON — Planes like the aging seaplane that lost a wing and crashed in Miami in December, killing all 20 people aboard, won't be subject to new federal rules designed to protect the safety of older aircraft.

The National Transportation Safety Board accused federal aviation regulators Tuesday of ignoring a mandate from Congress by exempting all airline planes with fewer than 30 seats from regulations that will require additional inspections of aging planes.

The NTSB has not determined what caused the crash of a Chalk's Ocean Airways seaplane that plummeted into a shipping channel Dec. 19 after its wing snapped off and it was engulfed in flames. The agency, which investigates accidents and makes recommendations for safety improvements, has found evidence that the wing was weakened by corrosion and stress. The Grumman G-73T Mallard was built in 1947.

As planes age, metal weakens, and wiring becomes more susceptible to short-circuiting. Congress passed the Aging Airplane Safety Act in 1991, which required the Federal Aviation Administration to mandate improved inspections and maintenance. Last year, when the FAA issued regulations ordered by the law, it exempted planes with fewer than 30 passenger seats. It also exempted planes designed before 1958.

"The safety board is concerned that the exemptions ... exclude airplanes such as the accident airplane," the NTSB said in a letter sent to the FAA. The letter said the NTSB also is concerned that the rules will not take effect until 2010.

"The FAA will certainly take a hard look at the NTSB's recommendations and respond to the board as quickly as possible," said Alison Duquette, an FAA spokeswoman.

The FAA has issued more than 700 directives designed to improve safety on older planes, she said.

FAA: Controller lost track of plane

Takeoff delay cited as factor in runway incident at O'Hare

A busy air-traffic controller who mistakenly sent two planes on a collision course on converging runways Sunday at O'Hare International Airport apparently forgot about one of the jets after a pilot delayed takeoff, a federal aviation official said Wednesday.

Planes were being lined up for rapid-fire takeoff in an effort to reduce a backlog of delayed flights late Sunday. After being cleared for takeoff, the pilots of a United Airlines passenger plane asked for a two-minute delay to recheck cockpit instruments, the official said.

That break in the action, caused by the United crew being on the runway but not ready to go, may have distracted the controller or disrupted the cadence of operations, the official said.

"We think it may have something to do with it," said Bruce Johnson, vice president of terminal operations for the Federal Aviation Administration.

The controller "missed the plane on the other runway when he did his [visual] scan," Johnson said. "We can't let this kind of thing happen again."

Airline fires pilot removed from flight

HOUSTON (AP) -- A Continental Airlines captain removed from a flight because another employee smelled alcohol on his breath was fired Tuesday, the airline said.

The pilot, who was not identified, tested above the legal limit for alcohol for pilots, the company said. He was dismissed two days after being removed from the aircraft on suspicion of intoxication, said Sarah Anthony, a Continental spokeswoman.

The pilot was scheduled for Flight 706, from George Bush Intercontinental Airport to Tampa, Fla., on Sunday. It was his first flight of the day.

He rode on an airport bus to the terminal with another employee, who reported to the airline that he smelled alcohol on the pilot's breath. The pilot was removed from the aircraft before passengers boarded, Continental said in a statement.

Lighting the way

A program tested at D/FW could help prevent deadly runway accidents - if it receives funding

Many aviation officials consider it the most dangerous part of a plane trip: moving across a runway just as another aircraft is taking off. Lights glow red in the pavement, signaling an American Airlines jet to wait before crossing a runway at D/FW International Airport.

The U.S. averages almost one runway incursion a day, creating the potential for serious accidents. Ground collisions between commercial airliners have been among the deadliest plane disasters. Pilots and safety officials are watching a program at Dallas/Fort Worth International Airport, the primary test bed for preventing such runway incidents.

Lights glow red in the pavement, signaling an American Airlines jet to wait before crossing a runway at D/FW International Airport.

The system uses a series of computerized lights embedded along a runway to signal pilots. It's more useful than the way they now get information – by looking out a cockpit window or relying on controllers.

A year into tests at D/FW, the Runway Status Lights program has won broad support from pilots and airport officials. But with funding constraints at the Federal Aviation Administration, the program may not expand fast enough to prevent another serious accident.

Incursions represent "a highly dangerous situation," said Capt. William Mino of the Allied Pilots Association, the union for American Airlines Inc. "The chance of loss of life is so great that any of them is too many."

Since 1990, the National Transportation Safety Board has included stopping runway incursions as one of its five "most wanted" aviation safety improvements. The independent agency, which makes safety recommendations to the FAA, wants pilots to get immediate warnings of possible ground collisions instead of waiting on air traffic controllers.

Airports in Boston, New York and Las Vegas have experienced high-profile near-collisions since last summer, prompting heightened attention from safety officials.

In the incident at Las Vegas' McCarran International Airport, a controller confused two departure aircraft and cleared an Air Canada jet just as an America West plane was taking off.

The America West pilot later said he was 100 feet above the Air Canada plane as he passed over it, according to the NTSB. (America West is now part of US Airways Group Inc.)

The worst runway incursion occurred in March 1977, when a KLM Boeing 747 attempting to take off from Tenerife in the Canary Islands collided with a Pan Am 747 coming from the other end of the runway. The crash, the deadliest in commercial aviation, killed 574 people.

How it works

At D/FW, Runway 18L/36R features the series of red lights embedded in the runway, flush with the pavement.

If another plane is crossing a runway, "takeoff hold" lights illuminate to warn pilots to stop their departure. If a runway is unsafe for entry or crossing because a plane is taking off, runway entrance lights illuminate to warn pilots to stay away.

The system operates for every plane moving across the runway, not just when someone has made an error, said Jonathan Bernays, assistant group leader for surveillance systems at the Massachusetts Institute of Technology's Lincoln Laboratory.

That means the system must be able to process as many as 3,000 light activation commands a day for a busy runway – one that operates up to 20 hours a day, with 50 takeoffs or landings an hour, at several intersections.

"If all we had to do was turn on one light every few minutes, it would be trivial," Mr. Bernays said. "What's hard about the status lights is doing it right every time."

The takeoff hold lights have been in place for four months. They're the second phase of the safety lights program that launched in March 2005 after two years of engineering and software testing.

The runway entrance lights were initially intended for a three-month evaluation.

But after an "overwhelmingly positive" reaction during initial testing, the program has remained in place, said Jaime Figueroa, the FAA's surface systems manager in Washington.

"The response has been very positive, from pilots, air traffic controllers and airport operators alike," Mr. Figueroa said.

But the system hasn't been flawless. Some pilots have been reported to taxi over illuminated lights. Other concerns remain about pilots seeing the lights go off and moving ahead without clearance from a controller, though officials say that properly trained pilots have handled the system well.

'Layered defense'

The system's designers are quick to note that the lights were never meant to be a first-line defense but a tool that helps in case of human error.

"We have a very low tolerance for accidents," said Mr. Bernays. "You need a layered defense. The expectation of this program is it provides an independent backup to all of the procedures and training that currently give us a very safe system."

The program's cost for one runway at D/FW was $2 million, though other sites could be less. The San Diego airport is launching its own lights test program using a different surface radar.

When the program might expand beyond there is unclear. The FAA is revamping its funding structure to implement key technology upgrades and has fallen short on plans to expand other surveillance infrastructure.

Meanwhile, airport officials and pilots in Boston, Chicago and Los Angeles are interested. The FAA even hosted a Japanese delegation interested in the safety lights technology, Mr. Figueroa said.

Pilots and safety officials say they're hopeful that the program will attract the funding needed.

The U.S. had 324 incursions in the fiscal year that ended last fall, including three close calls between commercial jets that were deemed the most serious, according to FAA data. That figure has dropped from 424 incursions in 2000.

"We are working hard and making progress, but we are not there yet," FAA administrator Marion Blakey told a Senate panel last fall.

Yukon geologist killed in helicopter mishap

A Yukon government geologist was killed Saturday when he was struck by the rotor blades of a helicopter.

Geoff Bradshaw, 32, died in the Wernecke Mountains north of Mayo, where he was doing mineral assessment field work.

An official with the department said Bradshaw and a co-worker were being picked up by the helicopter when he was hit by its rotor blades. He apparently died instantly.

"He had about 10 years' experience working in the field with helicopters, so from that point of view it's really surprising that he would be involved in such an accident," said Rod Hill, who manages the Yukon Geological Survey.

"He was also a very likeable guy. I mean, everybody liked him. He was really nice, he was professional, he was hardworking. It's hard to say enough good things about Geoff. He'll be really missed."

Hill said investigations are underway by both the coroner's office and the Workers Compensation Board. Hi

Airline Industry's Secret Safety Streak

The airline industry in the United States is setting a new safety record no one thought possible: zero passenger deaths since 2001.

Periodically, over the past several years, those of us who marshal around words and phrases for a living have taken a deep breath and decided to go ahead and dare to discuss in public the fact that the airline industry in the United States is - every hour of every day since the fall of 2001 - setting a new safety record no one thought possible: zero passenger deaths.

Since such a safety record is expressed in facts, it gives us a great opportunity - some might regard it as a temptation - to try to dazzle and impress you with statistics in telling the story, as well as the temptation to pick a pet reason why we've avoided fatal accidents for so long.

For their part, of course, the airlines refuse to talk at all about this amazing four-and-a-half-year record of perfect safety, believing that Americans are so weak-minded and timid that any reminder of mortality may drive you away from their airplanes.

Airline pilots and flight attendants, meanwhile, tend to be just plain superstitious about such things, holding the vague belief that the moment we mention a safe flight record, it will most probably end in tragedy. And, of course, to be truthful in the extreme, there is a high likelihood that, regardless of how good we've become, somewhere, somehow in the future - and despite more than 50 million successful flights since 2001 - there will be another accident.

If you're still reading and not calling Amtrak, good, because there's a lot more you should know about this incredible safety record, starting with the fact that it is - absolutely no pun intended - no accident.

Yes, it's certainly true - as a recent article in USA Today pointed out - that the presence of a marvelous "black box" device called an Enhanced Ground Proximity Warning System in every airliner has virtually stopped the type of accident we refer to as "Controlled Flight into Terrain," the sort of wholly avoidable tragedy where pilots make human mistakes and fly their perfectly good airplane into a ridgeline or sometimes onto flat ground.

And it's also true that several other technological advances, coupled with "lessons learned" changes in procedures, have rid us of other human-caused accidents, while the type of mishap due primarily to structural or mechanical malfunction has become almost dinosaur-rare.

But, as legendary radio broadcaster Paul Harvey would say, let me tell you the rest of the story, and it's a doozy!

First, I should tell you about a highly successful little operation at Moffet Field in California, run by NASA and called the Aviation Safety Reporting System. Pilots and mechanics and anyone with safety information to share can and do send in detailed reports of near-misses and almost-disasters, as well as narratives of what went wrong - or what might go wrong in the future because of a perceived problem - and the ASRS team investigates the report, strips the reporter's name from it, and adds the details to a growing safety hazard database.

There are great advantages, especially to a crewmember, for filling out the ubiquitous ASRS reports, not the least of which is a limited immunity from FAA "enforcement" action when the report concerns an inadvertent human mistake. But it also gives aviation professionals a way to immediately alert everyone to a problem without fear of the problem being ignored.

What the ASRS system and its reports do is give a living, breathing picture of the status of aviation safety, not as a result of airline spin doctors putting things in perspective, but from the honest and raw viewpoint of the troops on the front lines.

Incident reports fall into a wide variety of categories, and the folks who run ASRS make the most-often-seen categories available as specific datasets. These categories - such as Altitude Deviations, Air Traffic Controller Reports, Checklist Incidents, Controlled Flight Into Terrain incidents - and many more can be viewed at this Website.

Each grouping, when studied, gives a snapshot of the type of close calls and mistakes that are occurring out there every day - mistakes that fortunately have yet to metastasize into a major accident.

But wait a minute. If dangerous mistakes are happening every day, why are we so safe?

Two reasons. First, the fact that aviators and aviation safety professionals work hard to read, study, and apply lessons learned immediately. Second, because we have learned to work as a true team in the cockpit and beyond.

I promised you the behind-the-scenes revelation on why we've become so safe, and here it is: Tucked away in that ASRS dataset list is a category called "CRM & MRM Issues" - reports providing clear evidence that the primary reason we've racked up 4 1/2 years without a passenger death in the U.S. is a thing called Crew Resource Management and Maintenance Resource Management.

In a nutshell, CRM is an absolute reversal of the iconoclastic cockpit culture we used to have up to the mid 1980's, and if CRM had been imposed on "Star Trek's" Captain Kirk, it would have cost him his command.

Kirk, just like most airline pilots before the mid-80's (me included), was taught to be omnipotent and infallible and in need of no one's advice, let alone that coming from a subordinate crewmember. To be a Captain Kirk, you had to be ready, willing, and able to assume that you not only could be perfect - despite being human - but that you were, in fact, perfect. Therefore, the act of shutting up a subordinate by waving a finger in his or her face with the angry retort, "When I want your !&@*$% advice, I'll ASK for it!" was just part of the paradigm. Captains were God, and everyone else followed respectfully - or else.

CRM changed all that. The principles grew from a series of catastrophic crashes in the seventies in which the major causal factors revolved around one imperfect human mind controlling every decision in a culture that discouraged comment or correction.

One of those disasters occurred in the Canary Islands on March 27, 1977, when the chief pilot of one of the world's best airlines (KLM) made an unchallenged mistake and started his takeoff into fog without takeoff clearance. The resulting collision between two 747's killed 583.

CRM training - a pioneering effort to change the Captain Kirk syndrome and begun bravely by United Airlines in 1983 - essentially overhauled the cockpit culture. It told captains that if they weren't willing and able to encourage and maintain constant, non-confrontational input from all of their subordinate crewmembers, they could go fly for someone else.

At the same time, CRM training taught subordinate copilots and flight engineers and, later, flight attendants that they were co-equally responsible for the safety of everyone aboard, and that it was no less than their job to speak up and keep on speaking up if they saw a safety problem or an unsafe decision, especially if the captain was refusing to reconsider.

This was a huge cultural alteration, and like all cultural changes in a well-established human system, it didn't "take" without tremendous effort and many years of firm, determined training and the absolute unwavering support of everyone from the CEO through the training captains on down.

Today, however, there are no captains out there who can expect to keep their command very long by ignoring their junior officers because the culture has changed utterly to one of true teamwork, featuring multiple minds helping with each decision and double-checking against inevitable human error.

Captains still make the final decisions, but only with the input and counsel of their highly trained subordinates.

And the proof? Well, that new culture is what you see reflected over and over again in today's ASRS narratives. Fifteen years ago, the ASRS folks were receiving an increasing number of surprising narratives telling how CRM had saved the day. Today, it's the deviations from the CRM norm that are rare enough to merit their own category in the ASRS system.

In other words, what you see when you read those reports - and please do, anyone can go through them - are crewmembers self-assessing the occasional failure to adhere to principles of open and timely teamwork.

Yes, some of our black boxes have made a huge difference. But the silent revolution in the commercial cockpits - taking us from the days of Captain Kirk's false omnipotence to today's atmosphere of teamwork and open communication based on the recognition that no one is perfect - is the primary reason we've achieved four-and-a-half years of perfect safety.

What's more, those same principles - now being applied to medical practice nationwide - will eventually have the same effect on human error in healthcare. In fact, the principles of CRM work spectacularly in any human endeavor from school teaching and nuclear power plant running to the operation of your average newsroom.

As individuals, we can never be perfect, but as teammates, expecting always to compensate as a team for individual human error, we do achieve near perfection.


Is there a cure for the summertime blues?


Although post-vacation blues is not officially recognized by the American Psychological Association, it is a condition that seems to affect many of us. Why? When we're on vacation – whether we travel or not – we escape our daily routines. We indulge ourselves and adapt a more a flexible lifestyle. Returning to the reality of work is a shock.

According to an experiment published in the Journal of Applied Psychology (August 1997), study participants returned to their pre-vacation burnout level just three weeks after returning from vacation.

Here are 5 tips that may help you postpone the stress:

      1. Return to an orderly desk
      Before you leave, create a first-day-back to-do list.

      2. Take an extra day off
      Tell people you're returning to work a day later than you actually are. This will give you a chance to catch up on emails, voice mails and organize the paper that accumulated during your absence.

      3. Avoid Monday
      Return to work on a Tuesday. This will shorten your first week back and let you avoid the Monday blahs.

      4. Recover from your vacation
      If you're going out of town for your vacation, try to have at least one day home after your trip to ease back into your routines.

      5. Maximize your time off
      A survey conducted by Steelcase found that 43% of respondents still did some kind of work-related tasks while on vacation. Try to set some boundaries around the work that you'll do while away. Don't announce to your boss and co-workers that you're available at any time. And if you simply must check your email from the cottage, limit it to 30 minutes per day.

END with thanks to jetBlue